The clock strikes 12pm (midday). It’s time for lunch. For most, this is a routine experience of enjoying a meal, taking time out from your busy day and possibly even having a moment to chat and socialize with friends. For those suffering with an eating disorder, it’s a time of dread and anguish. In this article, Dr. Felicity Marcus, a Specialist Psychiatrist with an interest in eating disorders and adolescent psychiatry, explains why eating disorders are not about food.
Despite the fact that those suffering with an eating disorder have been thinking about food all day, the “voice” inside their head makes them feel guilty and a sense of shame for wanting to eat or trying that “high carb meal”. They live in a world where eating would mean a loss of control. It could even mean an overwhelming act that goes against their perceived body image or deep-seated beliefs about their food, weight, and appearance.
Thinness equates to happiness. Yet it is never ever “thin enough”.
The biggest misconceptions about eating disorders
Having worked extensively with treating individuals suffering from eating disorders, I’ve often been asked by others (some even professionals themselves) “why can’t they just eat?” “Aren’t eating disorder patients the same?”
The naivety of these questions highlights how little we know about these patients and their struggles, and how there’s still such stigma and judgment associated with this mental illness.
The biggest misconception with eating disorders is that their illness is about an avoidance of food and wanting to be thin. However (and very often), this is not the case.
Eating disorders are often the “tip of the iceberg”
The food is rather a symptom of much more complex issues. There are usually complicated underlying emotions that are at the root of the eating struggles.
It’s also important to realize that an eating disorder can serve a purpose. For example, in an environment where one is not in control, it provides a person with security, safety and reassurance.
I often explain this to patients and parents as “the iceberg effect.” This is when the eating disorder is the tip of the iceberg (what we can see).
What’s going on underneath is what’s really keeping the ice afloat.
The Probability of Eating Struggles
Disordered eating is most common in children and teenagers. Research shows 1 in 5 children and teenagers have disordered eating patterns, according to the Journal of the American Medical Association of Pediatrics in 2023.
This was the first global analysis of studies on this problem. The study also showed that eating struggles are more common amongst girls, older adolescents and those with higher body mass.
Not all countries are well researched
In South Africa, there are no studies that measure how common diagnosable eating disorders like anorexia and bulimia nervosa are. However, roughly 1 in 6 South African girls expressed attitudes and behaviors that could indicate a possible eating disorder or risk of developing an eating disorder. 45.3% of teenagers in South Africa report being “highly dissatisfied” with their bodies.
Patient treatment for eating disorders can be challenging
One of our biggest challenges in dealing with eating disorders in South Africa is the dearth of eating disorder services. Patients struggling with eating disorders can be managed in a hospital setting or as outpatients. While most prefer the outpatient form of treatment, management needs to be individualized. Treatment should be directed based on a person’s weight, the severity of their struggles, the supportive structures in their home environment and their motivation for recovery.
If a person is medically compromised, he/she needs to be stabilized in a hospital before any form of eating disorder intervention can be put in place.
While there are a few inpatient units across private and government psychiatric facilities, most of the care is done through outpatient services and patients seeking out their own individual practitioners. These include dietician, psychologist, psychiatrist etc.
It’s important to remember that whether one receives care as an inpatient or outpatient, there’s not one person (no matter how qualified), nor one medication that can treat an eating disorder. A team approach is always best due to the complexity and nature of the illness.
How do you know if someone is struggling with an eating disorder?
I often say that you don’t have to be a medical expert to know when someone is struggling with an eating disorder. Very often people will pick up on the signs, but then don’t know how to approach the topic.
Here are a few tips to help and support an individual in getting help early
- Always approach the subject without judgment.
- Choose a time and place where you will be safe and not disturbed.
- Avoid talking to someone before/after meals.
- Broach the topic gently. Remember that an eating disorder is usually a symptom of a much more complex underlying cause and emotional distress.
- Use first-person narrative: “I’m worried about you”; “I’ve noticed you are not eating as much at meal times.”
- Use open-ended questions like “I wonder if you’d like to talk about how you are feeling?”
- Don’t focus on food behaviors in isolation. This may cause them to become defensive/ deny their symptoms.
- Rather, focus on what is happening for them emotionally. Emphasize that you care about them and their emotional well-being.
- Open up the lines of communication.
End note
It’s very common for one to become defensive. Don’t take this personally. Remember that eating disorders can exist during emotionally challenging times. They serve a function and the person suffering from an eating disorder may not be willing to give that up just yet.
About the Author
Dr. Felicity Marcus is a Specialist Psychiatrist with an interest in eating disorders and adolescent psychiatry. She received her degree in medicine from The University of the Witwatersrand and began her medical career working as an intern at Chris Hani Baragwanath Academic Hospital. She went to work as a medical officer at Tara Hospital. There she developed a passion for the field of psychiatry. Dr. Marcus specializes in eating disorders, management of anxiety, depression and stress, including bipolar in adolescents. Her detailed biography is listed below.
